Heart failure (HF) is one of the leading causes of death in the United States and it is the most common reason for hospitalization. Previous studies have reported on the significant variation in hospital performance for the treatment of heart failure and the deviation from "best practices" despite the widespread dissemination of evidence-based guidelines. Recent studies suggest that substantial improvements have been made to narrow the quality chasm for inpatient heart failure care based on standardized process measures;however, little is known about how changes in process measures have affected patient outcomes. Although it is assumed that an increase in hospital performance on standardized process measures leads to improved patient outcomes, there is sparse empirical research that has validated this assumption. This exploratory study evaluates the relationship between hospital performance for heart failure on the evidence-based process measures of left ventricular assessment, ACE inhibitor/angiotensin receptor blocker at discharge, smoking cessation counseling, and discharge instructions within the 306 hospital referral regions (HRRs) across the United States and mortality at 7 days, 30 days, 90 days, and 1 year post-discharge from January 2003 to December 2006. A secondary aim will examine the potentially mediating relationship between market competition and the trends over time in hospital performance on standardized heart failure process measures within HRRs. A rich dataset that includes a national sample of more than 3000 hospitals from the Joint Commission will be linked with mortality and market share data from the Medicare Provider Analysis and Review (MedPAR) file as well as hospital characteristics from the American Hospital Association (AHA) annual survey and socio-demographic characteristics from the Area Resource File (ARF). Ordinary least squares (OLS) regression models will be used to analyze the data with SAS version 9.1 and alpha=.05.